HESI LPN
HESI Mental Health
1. A client's medication sheet contains a prescription for sertraline (Zoloft). To ensure safe administration of the medication, a nurse would administer the dose:
- A. On an empty stomach
- B. At the same time each evening
- C. Evenly spaced around the clock
- D. As needed when the client complains of depression
Correct answer: B
Rationale: The correct answer is B: 'At the same time each evening.' Sertraline should be administered at the same time each evening to maintain steady drug levels and effectiveness. Choice A is incorrect because sertraline can be taken with or without food. Choice C is incorrect as sertraline does not need to be spaced around the clock. Choice D is incorrect as sertraline is a scheduled medication and should not be taken on an as-needed basis for complaints of depression.
2. A 4-year-old child is admitted with a diagnosis of bacterial pneumonia. What is the priority nursing intervention?
- A. Administering antipyretics
- B. Administering antibiotics
- C. Monitoring fluid intake
- D. Providing nutritional support
Correct answer: B
Rationale: The priority nursing intervention in a 4-year-old child admitted with bacterial pneumonia is administering antibiotics. Antibiotics are crucial for treating the infection and preventing potential complications. Administering antipyretics (Choice A) may help reduce fever, but addressing the underlying infection with antibiotics is the priority. Monitoring fluid intake (Choice C) is important for hydration but does not take precedence over administering antibiotics. Providing nutritional support (Choice D) is essential for overall care but is not the immediate priority when managing bacterial pneumonia.
3. In a disaster at a child day care center, which child would the triage nurse prioritize for treatment last?
- A. An infant with intermittent bulging anterior fontanel between crying episodes
- B. A toddler with severe deep abrasions covering 98% of the body
- C. A preschooler with a lower leg fracture and an upper leg fracture on the other leg
- D. A school-age child with singed eyebrows and hair on the arms
Correct answer: B
Rationale: The toddler with severe deep abrasions covering 98% of the body would be prioritized for treatment last because these extensive injuries may require immediate attention and resources. The other choices present serious conditions but are not as severe or life-threatening as the toddler's injuries. The infant with an intermittent bulging anterior fontanel may have signs of increased intracranial pressure, requiring prompt evaluation. The preschooler's fractures, though serious, can be managed without immediate critical intervention. The school-age child with singed eyebrows and hair may have suffered burns but does not exhibit injuries as severe as the toddler's deep abrasions.
4. The nurse receives change of shift report on a group of clients for the upcoming shift. A client with which condition requires the most immediate attention by the nurse?
- A. Gunshot wound three hours ago with dark drainage of 2 cm on the dressing
- B. Mastectomy 2 days ago with 50 ml bloody drainage in the Jackson-Pratt drain
- C. Collapsed lung after a fall 8 hours ago with 100 ml blood in the chest tube collection container
- D. Abdominal-perineal resection 2 days ago with no drainage on dressing and fever and chills
Correct answer: C
Rationale: A collapsed lung with significant blood accumulation requires immediate attention to prevent respiratory compromise. Option A may also require attention, but the immediate threat to airway and breathing in option C takes precedence over the others. Option B has expected drainage after a mastectomy, and option D's fever and chills, while concerning, do not pose an immediate life-threatening risk as in option C.
5. A male client presents to the clinic stating that he has a high-stress job and is having difficulty falling asleep at night. The client reports having a constant headache and is seeking medication to help with sleep. Which intervention should the nurse implement?
- A. Determine the client's sleep and activity patterns
- B. Obtain a prescription for the client to take when stressed
- C. Refer the client for a sleep study and neurological follow-up
- D. Teach coping strategies to use when feeling stressed
Correct answer: A
Rationale: Assessing the client's sleep and activity patterns is crucial in understanding the factors contributing to the sleep difficulties and headaches. By evaluating these patterns, the nurse can identify triggers, stressors, and lifestyle habits that may be impacting the client's sleep quality and overall well-being. This assessment will guide the nurse in formulating an appropriate care plan tailored to the client's specific needs. Option B is not appropriate as it focuses solely on providing medication without addressing underlying issues. Option C is premature as a thorough assessment should precede any referrals for specialized studies. Option D, while important, should come after understanding the client's sleep patterns to provide more targeted coping strategies.